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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-34473L/„2U PERMIT EXPIRES 1 YEAR PROM DATE ISSUED (Complete in Triplicate) r��~ Application is hereby msde,to San Joaquin County for [ - s pp y q permit to construct and/or install the work berein�described. application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services./9� 1 ./ Job Address � 1 S. '4r1lel,1�� City S AQ_ Lot Size/Acreage Owner's Name /!n (�l'!r�/` �iC.f Address �g7� s, � e- t Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT O DESTRUCTION ❑ Out of ilStvlce Well O PUMP INS TION O SYSTEM REPAIR ❑ OTHER on torfiag Well C.1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL F PROP. LINE FOUNDATION (CULTURE WELL ELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA N ION SPECIFICATIONS fl Industrial O Open Bottom D Manteca is, o ell Excavation Dia. of Well Casing U Domestic/Priva te Gravel Pack acy Type of Casin Specifications M Public I'1 0th O Delta Depth of Grout Seal Type of GroutG IrriOationApprox. Depth ❑ Eastern Surface SeuI Installed by Repair Work Done U Type of Pump H.P. State Work e Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i Depth SIC Z' TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity-- No. Compartments PKG. TREATMENT PLT, 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. 6 Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line --� SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant mu call for all re uired i spgctions. Complete drawing on reverse side. Signed Title: �J �'� Date: DEPARTMENT USE ONLY Application Accepted by LI.A, �, ______ Date —��-9�_ Area �J Pit or Grout Inspection by Date Final Inspection by--> , r %�",' Date Additional Comments: _ Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES C? ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. . EH 13-24 ,t��7 l� ©� 1Tr7 ' " a 1� 1 A EH;�2e ll